<p><img src="/nairobi/PublishingImages/Excision%20endometriosis%201.jpg" alt="" style="margin: 5px;"/>
</p><p><strong><em>Dr Charles Muteshi analyses an ultrasound scan in his clinic at Aga Khan University Hospital Nairobi</em></strong>
</em></strong></p><p>Human female reproduction is a well-orchestrated process starting at pubertal transition through adulthood and concludes with the menopause. It is a process that lies at the heart of invisible intricate cellular processes and mirrored in outwardly bodily changes.
</p><p>At the time of puberty, the quiescent ovary throttles into activity following stimulation from brain derived hormones resulting in menstrual flow and regular ovulation. Data show secular changes in timing with earlier onset in recent times. The ovary is an organ that produces a multitude of hormones which control reproduction and play a role in other functions such as wellness, heart and bone health.</p><p>Hormone and oocyte production from the ovary is not infinite and these processes are closely controlled by an individual's genetic blueprint and environmental influences. There is great variation in amounts and duration in such a way that the biological clock is perhaps predetermined in each woman. It is clearly known that the ages between twenty and thirty-five years correspond to the highest reproductive potential.</p><p>Modern lifestyles and personal choices envisage that these biological processes may be modified to suit individual preferences. However, the biological clock which is person dependent is always ticking in the background. It is not always the case that this is easily noticeable especially with use of modern contraceptive methods.</p><p>Technological advancement makes it easy for cycle tracking applications to inform us certain fundamental events for instance when to expect a period flow or optimal time for fertility. Changes in cycle patterns could reflect important functional activities within the ovary. Though not accurate in predicting the biological clock, it may give cues that certain milestones.</p><p>In 2001 a team of experts convened the stages of reproductive ageing workshop (STRAW) to propose that the female adult life is distinguishable into three broad phases that encompass reproductive, menopause transition and postmenopause. These three stages are hinged upon the final menstrual period and not necessarily age dependent, though most women have the final menstrual period at the age of fifty-one.</p><p>There appears to be important biological changes that happen during the menopause transition period. It is a time when reproductive potential declines, menstrual cycle changes manifest and variations in hormonal activities become noticeable. The menopause transition is closed linked to ovarian functional potential that is measurable through ovarian reserve testing. When ovarian reserve starts to decline, hormonal outputs change and there may be cycle variations.</p><p>Individual women have a near constant menstrual cycle. During the menopause transition which may begin as early as ten years before the final menstrual period, cycles lengths begin to shorten. After several months to a few years, the cycle gets longer before becoming infrequent and finally the last menstrual period happens. This is usually defined by a period of twelve months from the final menstrual period and corresponds with the menopause.</p><p>It is during the menopause transition also that women notice onset of certain symptoms such hot flushes and night sweats, tiredness and mood changes, vaginal dryness and to some extend urinary symptoms. There may also be changes in sleep patterns and sexual drive and desire. At the heart of these symptoms is a decline in production of the hormone oestrogen by the ovaries. Oestrogen is also important in maintaining bone and heart health. It is therefore important to pay more attention to the menopause transition than waiting for the final menstrual period.</p><p>As the final menstrual period occurs on average at the age of fifty-one, and the menstrual transition could take anywhere between five and ten years, it appears sensible that after the of age forty, health professionals and women should focus on wellness during the transition. General health advice to maintain a healthy lifestyle and screening for breast and cervical cancer should also include enquiry into symptoms of the menopause transition. There are no tests that are undertaken to establish this important time in reproductive ageing.</p><p>In addition to quality of life and wellness, there is mounting data that indicate heart health protection when replacement of oestrogen is offered earlier in the menopause transition based on what is known as the threshold hypothesis. This goes hand in hand with advice on exercise and healthy dietary practices including adequate intake of calcium and vitamin D.</p><p>There are various forms and routes of hormone replacement and at present, we advocate body identical hormone replacement. These are hormones similar to what the body produces naturally and are reassuringly safe in most cases. It is important that prescription and monitoring of hormone replacement are undertaken by properly trained and experienced health professionals. There is no arbitrary limit to duration of use of hormone replacement, however, a review should be made at the expected time of natural menopause and agreement reached on when it could be stopped depending on symptom relief. </p><p><strong><em>By Dr Charles Muteshi, Consultant Obstetrician Gynaecologist and Fertility Expert at Aga Khan University Hospital, Nairobi</em></strong></p><p><strong><em>This article was first published in Business Daily Newspaper on May 6, 2022</em></strong>